A psychiatric diagnosis of the times
Dirk De Wachter
The title ‘Borderline-Times’ is inspired by the work of the American philosopher Richard Rorty1. In identifying the characteristics of our postmodern society, Rorty claims that ‘in postmodernity, the margin becomes mainstream’. Here he is pointing to a recognizable phenomenon in contemporary society: whatever first starts out at the boundary of society, subsequently becomes mainstream or the norm. Psychiatry deals with the boundaries of society, with what we want to forget, what we want to move to the margins in order to make it disappear. This is closely related to Foucaultian thinking concerning centre and periphery, power and powerlessness.
A second inspiration for the title comes from my own experience as a psychiatrist. When I started my career as a young psychiatrist, neurosis was the most important psychiatric diagnosis. Moreover, it was the default diagnosis. There was also a term for the rather vague boundary between neurosis and perhaps psychosis, literally called the border or ‘borderline’. Twenty years later, the meaning of the diagnosis of borderline personality disorder has changed and it has become one of the most common diagnoses in psychiatry and mental health. An extensive and detailed description of it is included in the Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Text Revision (or DSM-IV TR), which contains the standard classification that is used worldwide to give a name to people’s suffering.2 Does time then create new diagnoses, new psychiatric illnesses, new suffering?3 Does the DSM-IV offer a recipe for creating patients?
In the past twenty years, the diagnosis of ‘borderline personality disorder’ has gone from being nonexistent to being the most common diagnosis. One could rightly ask whether it should exist at all, but regardless of every such questioning, the fact remains that it is the most used diagnosis.
However, anyone studying the DSM-IV would come to the conclusion that we all suffer from borderline personality disorder. The DSM-IV mentions nine criteria, five of which are sufficient to receive the diagnosis. Let us look more closely at these criteria in order to support our claim.
We will illustrate each criterion by means of a quotation from one of the works of the contemporary and highly controversial French author, Michel Houellebecq. Houellebecq’s work is a remarkable and typical articulation of contemporary society and of the position of human beings in that society. His work is both an inspiration for and illustration of what matters today.4
I have no intention of embarking on a pessimistic or a fin-de-siècle discourse on culture; rather than analyse, I will simply, in the phenomenological tradition, try to observe the reality of life today.
Criterion 1: Abandonment anxiety
Certains êtres éprouvent très tôt une effrayante impossibilité à vivre par eux- mêmes: au fond ils ne supportent pas de voir leur propre vie en face, et de la voit en entier, sans zones d’ombre, sans arrière plans.
Claim: ‘We all have abandonment anxiety’.
We live in a time of individualisation and loneliness. Our liberal society puts the individual in such a central position that the development of a self-creating reality has become an individual task. We live in an era that imposes on each individual the belief that he or she is obliged to develop and create his or her own self. We regard this individual duty to create one’s own distinctive life — this freedom to decide about one’s own life — as a twentieth-century achievement, emancipating the human being from church and state. We consider it to be an achievement worthy of being defended, but nonetheless it has come with an inevitable price of loneliness, of ‘alone-ness’. When our lives do not measure up to expectations created by the media, when the task of self-determination is not altogether successful, then a stark confrontation with loneliness ensues. In this sense, psychiatry primarily accommodates people who are lonely.
Despite the new and unavoidable social reality, it is not so easy for us to adapt to the task of individuality, ‘alone-ness’, loneliness. As individuals, we still yearn for warmth and security, whether that of the family or of a small community, and thus we end up feeling an awkward tension with society. On the one hand, there is the difficult task of individually determining our fate in life, and on the other there is the continuing yearning for warmth and security. This is what leads to our abandonment anxiety.
The disappearance of the nuclear family as a source of security is a social reality. As a society, we have observed and accepted the change. Yet our deep longing for security has not gone away, and fundamentally we still yearn for that nuclear family. A recent survey of teenage youths showed that they dream of the very classic family: husband, wife and children. If you confront this dream with reality, you enter into a field of tension between desire and reality, and it is precisely this field that causes our abandonment anxiety.
The death of universals and foundations, the death of grand narratives, the disappearance of a self-evident support network or framework confronts us at a deeper existential level with abandonment anxiety. The death of consensus, of continuity and unity in society, throws us forcefully back to the duty of self-determination and to the individual search for coherence. It places us all alone on the path of a fragmented reality.
Criterion 2: Unstable and Intense Relationships
Il ne fallait pas se monter la tête, cela n’ arrivait presque jamais, pourtant dans certains cas, extrêmement rares, presque miraculeux cela pouvait arriver.
Claim: We all have unstable and intense relationships
At the start of the nineteenth century we somehow got the idea in West-European culture that relationships were about ‘loving each other’. Thus romantic love was born. Until then relationships were not subject to such high expectations. Marriage arrangements were struck in much the same way as other economic arrangements in society. However, romantic love now became the guideline for a relationship, its necessary basis, its condition, its touchstone. This too we regard as a valuable achievement, and we are willing to come to the defense of love. Nonetheless, it still makes reality of relationships more fragile. Love may intensify relationships, but it also makes them more unstable. This claim is confirmed on a sociological level by the duration of relationships: in our country the average length of a marriage is 12.5 years, 7.5 for those living in urban areas – and is even shorter for non-marital relationships. Love, as a sustainable good, turns out to be difficult to realize.
The reality of our relationships is also affected by the way in which our lives are on the whole embedded in a consumerist throw-away society. In this context also, the judgement that something or somebody is no longer novel, young, or cool can more easily lead to taking a distance, dropping somebody, or some other kind of ‘throw away’ action.
The economic and consumerist reality in turn pushes us towards hedonism. Life ‘needs’ to be fun, relationships need to be fun… and when they no longer are fun, then we ourselves have to take different decisions in order to continue our search for self-creation and self-determination. We need to take care of our own selves and keep the fun in our lives.
Relationships have also become more transient because time seems to be moving faster. Thanks to rapid societal changes, both technological and social, we are acutely aware of time passing at an ever increasing rate. We are still not fully cognizant of this change, nor are we able to adequately guage it, since we ourselves are too much part of the change and are too close to it. Nonetheless, the present generation needs to be able to adapt to the accelerating changes in a world that’s fragmented, globalized and relentlessly changing. This has led to ‘the death of history’ and to life in some hypertrophic ‘now’. It has to be good now; there is little recourse to ‘it was good in the past’ or ‘it may become good in the future’. Everything is judged in the now, and needs to be evaluated ‘now’.
This death of history is also the death of the afterlife: ‘nothing will be returned to us later’ and that’s why we ‘need to maximally take and enjoy’. This has an enormously destabilizing effect on our relationships. People long for everlasting romantic love. Perishability, fragmentation, complexity, and transience are the key words that characterize contemporary society.
Criterion 3: Inadequate control of aggression
C’ est foutu depuis longtemps, depuis l’ origine … Lance-toi dès ce soir dans la carrière de meurtre; crois moi mon ami, c’ est la seul chance qu’il te reste.
Claim: even though we might deny this criterion at first sight, we live in a time that is saturated with aggression.
Aggression is part and parcel of our culture and our daily life. All we need to do is watch an old recording of a thrilling police series from the 1970s5 that captivated so many families on Saturday evenings and compare it with the visual images on television, or in computer games today. The speed of the images has undergone an incredible increase, as has the presence of very extreme and realistic violence. Pointless violence – violence as a diversion to pass the time – is a new phenomenon. Violence is not new of course, but previously it often had a purpose, and a further aim. Pointless violence or violence as diversion is a new phenomenon.
Vandalism and hooliganism are part of this broader phenomenon. Hooliganism is violence as entertainment, and has become a recreational reality. Buildings are no longer broken into by cleverly bypassing safes or codes, but by ramming a vehicle into a building… Road rage has become a normal part of daily life. People feel increasingly powerless in face of these escalating phenomena, and the media ensure on a daily basis that our habituation to violence is maintained.
We also accept the paradox that society is combating violence with increasingly heavy-handed violence and with displays of power that sometimes border on the grotesque.
Perhaps we should search for the explanation of this phenomenon in the French philosopher Bataille’s claim: ‘Because we are finite, we go too far .’6
Criterion 4: Personality Disorders
La difficulté, c’ est qu’il ne suffit pas exactement de vivre selon la règle … La règle est complexe, multiforme … Le domaine de la règle ne vous suffisait plus; vous pouviez vivre plus longtemps dans le domaine de la règle …’.
Claim: We all ask ourselves ‘Who are we? What are we doing here? Where are we going?’
Many would prefer to avoid these difficult questions. If there is no god, then who put us here, what are we doing here and for what purpose? This question is perhaps posed with most clarity and urgency when something serious happens in a person’s life.
Quite a number of changes in society confront us with an increasing number of existential issues. The traditional templates have disappeared, the path we follow is no longer set, gender roles have become less well defined, and even sex and identity can be questioned and modified today. Fashion, lifestyle, looks, design are important and seem as if they have to direct the course of our lives. We want to look like actors on TV, we want to decorate our houses in the style represented in the colour supplements of weekend newspapers. We live in a culture of excessive talk, one also saturated with an excess of visual images.
People identify with an image, but the images change incredibly fast. Bach could wear the same wig for fifty years; his appearance remained unchanged. Today this is inconceivable and the exterior evolves too quickly for us to keep up. However, when the exterior evolves to such a degree and attains that kind of importance, then it becomes increasingly difficult to find depth or grounding, or to choose stability and rootedness as a point of departure. Then the death of the human being makes its entrance.
Today we constantly hear the message that we need to choose what we ourselves want, that we need to do ourselves what we ourselves truly enjoy doing, that we need to follow our own path that yet keeps up ‘with the times’. However: what do I want to choose, what do I enjoy doing, what is my path, and when am I keeping up with the times? These are incredibly difficult tasks, and they lead to very difficult questions and problems in the building of identity in youths and adults.
Criterion 5: Emotional lability
Le désir lui-même disparait; il ne reste que l’amertume, la jalousie et la peur surtout, il reste l’amertume, une immense, une inconcevable amertume aucune civilisation, aucune époque n’ont été capable de développer chez leur sujets une telle quantité d’amertume..
Claim: we are all emotionally labile, and this is closely related to the previous criterion. When there is no deeper structure, and only a superficial culture, when everything is geared towards immediate satisfaction, when there is no foundation, no basic level to fall back on, then we all suffer emotional lability.
The absence is depth is connected to the economics of pleasure, which in turn gives rise to a culture of consumption where the ephemeral, the new, the perishable are continually put forward as immediately reachable goals. We have to live in the permanent ‘now’: history represents the ‘old’, and ‘now’ represents the ‘new’ and ‘hip’. In an extremely hedonistic advertising culture like the one we have today – in which even our own past disappears – emotional lability is unavoidable.
So, we need take a trip once a year, with a city trip in between. Every weekend we surely need to do something fun, experience something fantastic. We no longer have the time to enjoy a positive experience; each time it needs to be an enjoyable experience. The economy knows very well that pleasure is an important economic good; we live in a culture of pleasure that forces us to feel good constantly. If we don’t, then the solution for depression is a pill with which we can, as quickly as possible, return to functioning in a culture of pleasure. We have to feel good again, right at this very instant. Psychotherapeutic discourse carries the message ‘this can take a while and you may feel worse initially’, a message that scares off many people. Stomach reduction trumps a laborious diet, and the instant solution suppresses fundamental, difficult and slow change.
Criterion 6: Impulsiveness
L’objectif principale de sa vie avait été sexuel; il n’était plus possible d’en changer.
Et puis je prends des calmants, et tout s’arrange, tout s’arrange.
Claim: We may think we can escape this criterion, but nothing is further from the truth. In any case, we are also much more impulsive when it comes to sexuality. Sexuality too is part of the culture of pleasure. All studies show that we deal very casually with sexuality and that we score very low on relational loyalty. This has become a sociological fact, fed by widely watched reality TV shows such as Temptation Island, Jersey Shore and Ex on the Beach .
Belgium has the unfortunate reputation of having the highest use of psychopharmaceuticals and benzodiazepines (tranquilizers and sleeping aids). The use of soft drugs has become engrained in every school, and alcohol consumption has become almost unavoidable for anyone who wants to have a social life.
We are likewise impulsive with our diets, a phenomenon that is obvious generally in society and not just at the level of the individual. The phenomenon of obesity, common in the United States, has also arrived here Supermarkets are full of processed, calorie-rich foods, which are consumed quickly, easily and impulsively. We live in the chasm between a culture of bulimia, and an impossible ideal of slimness.
We are impulsive with money and are stimulated to be impulsive with it: ‘money rolls’. For instance, gambling addiction is a new and continually growing problem. The number of people going into debt is increasing each year. The services for budget guidance and budget management complain about a shortage of staff.
The death of history has turned saving into a pointless activity. Our parents and grandparents saved for the future of their children and grandchildren. Today the economy needs ‘moving, rolling money’ and we allow ourselves to be tempted by enjoying ‘now’ and consuming ‘now’.
Impulsive driving is considered by the DSM-IV as a separate category. This is a widespread sociological reality and not a psychiatric reality. The fashionable terms today are ‘fast’, ‘short’, ‘kick’, ‘new’, but we project these facts onto the patients. This looks very much like a Foucaultian system of projection.
Criterion 7: Meaninglessness and Emptiness
J’ai si peu vécu que j’ai tendance a m’imaginer que je vais pas mourir; il parait invraisemblable qu’une vie humaine se réduise à si peu de chose..
Claim: We all suffer from meaninglessness and emptiness.
The secularization or declericalisation of society plays a part, as does the end of ideologies and of grand narratives. Relativism, skepticism, and cynicism have become replacement attitudes. We live today in a cynical world and in a world of doubt and despair.
Meaning is a key concept within the practice of systemic therapy. Meaning is not something that is supported by the individual, but is a societal and communal happening. Meaning has to be supported by a culture and a tradition for it to be kept alive, to be grounded and to be lasting. Meaning cannot be retranslated into the language of a hedonistic, rapid-fire culture saturated with kicks. Meaning is related to being anchored and connected. It is a social happening.
Eclectic spirituality often causes even more meaninglessness, since meaning is ‘lost’ over and over again. Those who go shopping from guru to guru, from New Age to Tantra Yoga, often become even more disillusioned, because nothing really seems to offer them an answer.
Also within the arena of healthcare it no longer seems to be the case that ethical questions are asked, or that they may or can be asked. What is a psychiatric hospital in today’s society? What is the purpose of what we’re doing? And, furthermore, can we even still ask these questions?
Public policy does not seem concerned with the big questions. Who today is concerned with the question: “What does care mean in a postmodern society?” We ask practical questions about practical, concrete, and visible realities; we endeavour to propose technically adequate and qualitative policies, we regulate and calculate… We search for a ‘situational ethics’ but not for embedding these questions in a broader ethical perspective.7
And yet, many problems in healthcare probably have less to do with funding and finance than with meaning and purpose. Can we still ask ourselves: ‘Why do we not have any problem investing large sums of money in an advertisement for a new perfume or product, but have much more difficulty investing in lifelong care for seniors with dementia? Has this not become a serious problem for society?’
Criterion 8: Self-harm and Suicidal Thoughts
J’ai deux paires de ciseaux … L’envie persiste, grandit et se transforme. Cette fois mon projet est de prendre une paire de ciseaux, de les planter dans mes jeux et d’arracher..
Claim: Perhaps we may not inflict self-harm on ourselves but it is a problem for society, a social phenomenon that is connected to the quest for meaning and identity.
Our country also has a questionable reputation concerning suicide prevention, and has a very high suicide rate. The rate is even higher in Japan, which is now dealing with the phenomenon of group suicides among youths. This is not only a problem peculiar to psychiatric patients: it is a problem for society, and it is a problem of meaninglessness and depression, even though probably not all suicidal persons would be clinically depressed.
We live in a culture that is obsessed with the body, and its self-harming aspect is drawing closer. Given the current success of plastic surgery and aesthetic surgery, the dividing line between surgery and self-harm has become very thin. There is a drive and continual striving for ‘beauty’, for more ‘beauty’, despite the pain that comes with many of these operations.
In the underground culture of Japan – where trends are often set – people are dealing with the phenomenon of tattoos, piercing, scarring, extended tongue piercings to give the tongue a snake-like split (considered to be cool and erotically important). Here the distinction from self-harm disappears. Girls have the tips of their little fingers amputated, because this is symbolic of ‘belonging’ (identity). The boundary of what considered exterior needs to extended further and further so that the subject can still feel. One does not feel mentally, but instead one feels through physical pain. This is related to the emphasis placed on the exterior and to the search for identity. Emptiness inside impels a search for more exteriority, which in turn hollows out the interiority.
Some questions in conclusion
Are we now all sick? What in fact does it mean to be psychiatrically ill? Should we then heal the whole world?8
Is this profession still practicable?
Is there a place for art?
Was it better in the past?
What should we do about it?
Epilogue: “I am condemned to be free. This means that no limits to my freedom can be found except freedom itself or, if you prefer, that we are not free to cease being free”9
1 Richard Rorty’s works include Philosophy and the Mirror of Nature (1979), Consequences of Pragmatism (1982), Irony and Solidarity (1980), Achieving Our Country (1998). The latter two works were translated into Dutch as Contigentie, Ironie en Solidariteit (1991) and De voltooing van Amerika (1998).
2 By means of which it also suggests a universality, a culture- and norm-free guide.
3 At the same time, the new versions of DSM abandoned other diagnoses. Does time forget these other diagnoses and other types of suffering? For instance, in the 1950s the diagnosis of ‘nymphomania’ was often noted in files, often of women who were transferred from ‘indigent female institutions’ to psychiatric hospitals. What could this diagnosis mean today?
4 Michel Houellebecq: Extension du domaine de la lutte (1994), Les particules élémentaires (1996), Rester vivant et autres textes (1999), Lanzarote (2000), Plateforme (2002), La poursuite du bonheur (2002), Soumission (2015).
5 For example, Mannix or The Fugitive …
6 George Bataille, philosopher and author (1897-1962) of, among others, Histoire de ‘l oeil (1927), Le bleu du ciel (1935), Le mort (1943). The first and last were translated into Dutch as Het oog and De Dode, published in the series Rainbow Pockets. Further philosophical works include La part maudite (1949), La Litérature et le mal (1957), Les larmes d’ eros (1961). Bataille is often called the philosopher of violence.
7 For more on these questions and set of issues I refer to Mark Ledoux’s book: Waar zijn we toch mee bezig? Institutionele Psychotherapie in weerstand en dialoog met de Kwaliteitspsychiatrie. (Literarte, 2004).
8 Let me refer here to Levinas’s ‘the little kindness’, further discussed in Dirk De Wachter, ‘Ich Hatte Viel Bekümmernis’ concerning the concept of responsibility in E. Levinas. Patiënttoewijzing in de psychiatrische verpleegkunde, Garant, 1988, chapter 3, pp. 45-51. See also ‘Emmanuel Levinas in het dagcentrum,’ in Psychiatrie en Verpleging, nr.4, 2004.
9 J.P. Sartre, L’être et le néant, 1943. Translated as Being and Nothingness, Hazel E. Barnes (trans.), Washington Square Press, 1992.